A parent brings a 4-month-old infant to the clinic.
The infant has had a runny nose, a slight fever, and a cough for the last two days.
Which of the following findings should alert the nurse that the child is in acute respiratory distress?

H.

Choice A rationale

Monitoring the oxygen saturation is an important nursing intervention following the administration of albuterol. Albuterol is a bronchodilator and should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice B rationale

Deep tracheal suctioning is not typically required following the administration of albuterol unless the patient has excessive secretions or difficulty clearing secretions.

Choice C rationale

Discussing potential asthma triggers with the client is an important nursing intervention. Understanding and avoiding triggers can help prevent future asthma exacerbations.

Choice D rationale

Obtaining a sputum culture is not typically required following the administration of albuterol unless there is a suspicion of a respiratory infection.

Choice E rationale

Positive pressure ventilation is not typically required following the administration of albuterol unless the patient is in severe respiratory distress.

Choice F rationale

Allowing the client to take a position of comfort can help improve breathing and should be encouraged.

Choice G rationale

Discussing aggressive respiratory treatment options is not typically required following the administration of albuterol unless the patient’s condition is not improving or worsening.

Choice H rationale

Weaning the supplemental oxygen may be appropriate following the administration of albuterol if the patient’s oxygen saturation has improved.

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.